Farming 2: Farm Wounds/Amputation Portal
Introduction/Etiology
Farm and industrial machinery has great potential to cause devastating limb injuries. Accidents can occur in a split second. Equipment such as balers, augers, corn-pickers, and combines have rotating, chopping, and moving parts that can and do easily catch clothing. Many pieces of farm equipment are powered from a tractor by a power-take-off (PTO) device that is often spinning at 1000 X per minute. In an instant, a fall or catch on these moving machinery parts will rip and tear off a limb or twist it around the rotating piece.
In assessing farm injury patients, health care providers commonly focus on the damaged area of injury. However, the force that has caused the injury often may have thrown the patient into sharp equipment edges or other objects. Patients are easily able to suffer life-threatening injuries (such as a hemothorax) that need immediate treatment. Follow the ABCs.
Prehospital Consideration
A patient’s limb that has been entangled into rotating farm equipment may be difficult to disentangle. A physician may be required at the emergency scene to amputate the limb to free the patient before he or she bleeds out their entire blood volume. If possible, as a first step, dismantle equipment (eg, undo bolts and screws; remove metal coverings). Another option is to dismantle equipment to a point where the patient may be safely transported to a hospital with the amputated or partially amputated limb still entangled in the equipment. Surgeons are then able to carefully remove the limb from the equipment in a controlled environment where they can attempt to preserve as much of the limb as possible.
General Treatment of Farm Wound Patients
Airway. Treat as needed.
Breathing. Place patient on O2 @ 15 L/min with non-rebreather mask; assist ventilations as necessary.
Circulation.
- Control uncontrolled bleeding:
- Direct pressure to bleeding sources.
- Elevate the extremity.
- To slow bleeding, put pressure on arterial points that supply the injured area.
- Use a BP cuff inflated just enough to slow blood flow to a trickle in the injured extremity.
- Place a Kelly clamp directly on arterial bleeders with rubber covering on teeth area or improvise using IV tubing on teeth area so that the teeth of clamp will not dig into the artery.
- Use a tourniquet as a last resort.
- Trauma Dex may be useful in
some situations.
- Initiate IV therapy. Use 2 large-bore IVs (in non-injured
extremities) with
warm fluids. Replace IV fluids at 3 cc/1 cc of
blood loss.
- Blood product replacement
- Packed Red Blood Cells (PRBCs). After giving the patient 2 L NS, replace with blood products (10 cc/kg PRBCs). Give up to 2 units of O-negative blood until type-specific blood is available.
- Fresh Frozen Plasma (FFP). Give FFP if the patient’s protime and/or PTT are elevated and the patient is at risk for continued bleeding. Give FFP to replace blood-clotting factors until INR (International Normalized Ratio) is normal (= 1.2).
- Give cryoprecipitate to patients with fibrinogen <150.
- Give platelets to patients with platelet count <100.
- Monitor for hypovolemic shock and continue to treat as needed.
Medications
- Treat pain.
- Antibiotics: Agricultural wounds are dirty; treat with broad-spectrum antibiotics prophylactically. (See Prophylactic Antibiotics in Farm Injuries, this portal.)
- Administer tetanus prophylaxis.
X-rays
- Bones may have been twisted outside their normal range of motion. Check bones and joints proximal and distal to injury for fractures and dislocations.
- Rule out foreign bodies.
Labs
- Gram stain of wound drainage may show gram-positive rods or spores.
- Culture of the wound or blood culture may show specific organisms in infected wounds.
Care of Wound
- Gently cleanse and rinse off dirt, gravel, or contaminants from wound with NS.
- Wrap moist areas of injury with moist NS dressing.
- Keep intact skin dry if possible.
Approach to a Patient with an Amputation
Care of Amputated Part
- Rinse off dirt, gravel, or contaminants from limb with NS.
- Wrap moist areas of limb with moist NS dressing.
- Keep intact skin dry if possible.
- Place limb in a plastic bag on ice. (Ice coolers work well.)
Considerations and Variables for Reattachment
The following guidelines may be useful for patients. Please keep in mind that surgeons differ in their opinions about amputation care. Contact the re-implantation team early for determination of reattachment options.
- Mechanism –
Clean versus Twisted versus Dirty
- Clean – A limb that has been cleanly severed is usually easier to reattach. Patients usually have less blood loss.
- Twisted – A limb that has been twisted during amputation is usually more difficult to reattach.
- Dirty
– A limb with a dirty wound may be difficult to debride, and
infection risks increase greatly.
- Time Since
Injury
- If the time between the injury/amputation and reattachment is:
- < 6 hours—reattachment usually successful
- From 6 to 12 hours—success is more unpredictable
- > 12 hours—chances of infection increase, so
usually not successful
- Amputation
Care Since Injury
- The shorter the ischemia time, the better the outcome.
- Viability is 4 to 6 hours (if limb has been kept
at room temperature) and 18 hours (if limb has been kept cool).
- Finger
Amputations—The approach to an amputated
finger varies depending on the finger involved
and the amount of the finger amputated.
- Distal beyond distal interphalangeal joint (DIP)—A surgeon may choose to pin the amputated part. However, capillaries and veins may be too small to reattach here. The severed finger part may be used to graft the end area.
- Mid Phalanx—Successful reattachment is more likely. Reattachment is usually successful on thumbs and fingers 3 and 4. Chances for success are less likely on index fingers and finger 5.
- Proximal Phalanx—Chances for successful reattachment are likely for severed fingers proximal to the mid phalanx.
- Place nails to have a path for new nails to grow.
Infection Considerations in Farm Injuries
Wounds sustained while working in agricultural environments can be grossly contaminated with a myriad of organisms. Soil, air, animals, and equipment in farm environments can be sources of mold, dirt and dust, chemicals, manure, and bacteria. The most common organisms cultured from farm wounds are Enterobacter, Klebsiella, xanthomonas, and Pseudomonas.1 Gram-negative organisms dominate wound infections, though gram-positive organisms are also prevalent.
Early meticulous local care of the wounds is essential to decrease the risk of the patient developing a significant infection. This includes the careful cleansing of the wounds to remove all particulate matter and reducing the bacterial contamination as much as possible. The use of copious irrigation of the wounds with NS is very helpful in decontaminating the wounds. Devitalized tissue should be debrided from the wounds to decrease the risk of wound infection. If a great deal of tissue is injured due to crushing and destruction, initially keep wound open. Use caution when closing farm wounds due to their high infection rates.
Prophylactic Antibiotics in Farm Injuries
While the use of prophylactic antibiotics in wound care is controversial, it is a consideration in contaminated farm injuries. You may want to consult your trauma center for their recommendation. If prophylactic antibiotics are given, use broad-spectrum antibiotics to cover both gram-positive and gram-negative organisms. Some antibiotics combinations that are commonly used prophylactically in contaminated wounds include:
- Fluoroquinolone (ie, ciprofloxacin, levofloxacin, or ofloxacin) plus a penicillin or
- Fluoroquinolone plus a cephalosporin (such as cefoxitin or cefotetan).
Special Considerations of Necrotizing Fasciitis and Gas Gangrene
Many necrotizing fasciitis and gas gangrene infections are associated with agricultural injuries. These infections can quickly spread, causing irreversible damage to tissues, which can quickly progress to tissue necrosis then on to systemic sepsis and death. Early recognition and aggressive intervention in patients with these conditions is imperative. Unless treatment is started early, there is frequently rapid progression from a mild process to one associated with extensive tissue destruction, systemic toxicity, loss of a limb, or death.5
The accurate diagnosis of necrotizing fasciitis or gas gangrene is frequently not possible without surgical exploration. Soft tissue x-ray, CT scans, and MRI may help in the diagnosis if air is in the tissues. A significantly elevated serum creatine kinase (CK) may suggest muscle tissue involvement by the infecting bacteria but is not accurate for making the diagnosis.
Necrotizing Fasciitis
Necrotizing fasciitis is a deep-seated infection of the subcutaneous tissue that results in progressive destruction of fascia and fat. Group A Streptococci, Enterobacteriaceae, and anaerobic Streptococci are common pathogens for necrotizing fasciitis. Called flesh-eating bacteria, these eat away and destroy soft tissues such as fat, muscles, muscle sheaths, and skin.
Symptoms of Necrotizing Fasciitis4
- Severe pain in area – often out of proportion to the clinical findings
- Swelling and hot area around wound
- Wound may initially be pale and progress to brown or bruised looking skin
- Fever
- Patient appears and feels ill
- Yellow clear or pus-like fluid draining from wound
- Progresses to sepsis and shock
- Involved extremities lose pulses and function.
Treatment of Necrotizing Fasciitis
- Early and aggressive surgical exploration of the wound with debridement of necrotic tissue.
- Antibiotic use in necrotizing fasciitis: Administer
antibiotics with
gram-positive coverage for 2 weeks using one of the following drugs:
- Meropenem: 1 g IV every 8 hours
- Imipenem 1 g IV every 6 hours
- Ertapenem 1 g IV every 24 hours
- Piperacillin/tazobactam 3.375 g IV every 6 hours
- Ticarcillin/clavulanate 3.1 g IV every 4 to 6 hours
- Unasyn 1.5 to 3 g IV/IM every 6 hours
- Clindamycin (900 mg IV every 8 hours) and penicillin G (4 million units IV every 4 hours)
- As an alternate, one of these drugs may be used: clindamycin plus either levofloxacin, gatifloxacin, or moxifloxacin.
- Hemodynamic support as needed.
Gas Gangrene
Gas gangrene (clostridial myonecrosis) is most commonly caused by clostridium perfringens. The distinction of true gas gangrene from anaerobic (necrotizing) cellulitis on clinical grounds is often difficult if not impossible. Patients with anaerobic cellulitis usually demonstrate less systemic toxicity than patients with gas gangrene. Another distinction is that anaerobic cellulitis involves the skin but not the fascia and deep muscle. Nevertheless, surgical exploration and debridement is frequently required to distinguish between the two entities. At the time of surgical exploration in patients with anaerobic cellulitis infection, the muscle at the adjacent periphery is normally bright red, bleeds readily when cut, and contracts when pinched. In patients with gas gangrene infection, the muscle at the edges of the gas gangrene is gray or brick red and does not bleed when cut or contract when pinched.2
Symptoms of Gas Gangrene4
- Initially pale to brown blanched and bronzed skin
- Subcutaneous air: Crackly sensation when pressed with fingers
- Develops darker bullae and blebs
- Serosanguineous drainage
- Patient appears acutely ill
- Elevated temperature
- Progressively rising pulse rate
- Diaphoresis
- Persistent pain despite pain meds
- Rapidly progressing shock and sepsis
- Gas may be apparent on x-ray
Treatment of Gas Gangrene
- Early and aggressive surgical exploration of the wound with debridement of necrotic tissue. Surgical debridement of necrotic tissue harboring the necrotoxins may include amputating or dissecting out the area involved.
- Antibiotic use in gas gangrene (clostridium perfringens).
Give 2 weeks of one
of the following drugs:
- Penicillin G 10 million units IV every 4 hours
- Clindamycin 900 mg IV every 8 hours
- Piperacillin/tazobactam 3.375 g IV every 6 hours
- As an alternate, one of these drugs may be used: imipenem, meropenem, ertapenem
- Hemodynamic support as required to maintain stability.
- Use hyperbaric oxygen therapy (HBO) for anaerobe
infections to saturate
surrounding tissue to decrease its chance of
becoming necrotic. HBO limits
exotoxin formation, limits bacterial growth, and decreases tissue
edema. Three
HBO treatments are done in the first 24 hours, and subsequent
treatments are
done based on surgical recommendations.
- Consider transferring complex cases.
References
- Sterner, S. Farm injuries: How can the family farm be made a safer place? Postgraduate Medicine, vol. 90/no2/August 1991, p.141-150.
- Ivatury, RR, Cayten, CG. The Textbook of Penetrating Trauma. Williams and Wilkins, 1996, p.41
- Cunha, B. Antibiotic Essentials. New York, Physicians’ Press
- www.nlm.nih.gov.medlineplus
- Stevens, DL. Necrotizing infections of the skin and fascia. In: Up To Date, Rose, BD (Ed), Up To Date, Wellesley, MA, 2002.